Bustin Barriers

Camp for Youth with Special Needs

Physical Clearance Form

2015

______

Camper’s Last Name First Name Middle Initial

Date of Birth: ____/____/_____ Race: ______Gender: F / M

Mo / Day/ Year

Grade in School: ______Name of School Attending: ______

Parent/Legal Guardian: ______

Address: ______

City: ______State: ______Zip Code: ______

Daytime Phone Number: ______Evening Number: ______

Emergency Contact: ______/______

Name/Relationship Contact Number

In Case of Emergency – Preferred Hospital: ______

Parent/Guardian/Medical Provider of Camper – Please review all of the following questions and answer them to the best of your ability. For the “Yes” answers, please provide details. Use back of the page if necessary.

  1. Please list any and all diagnoses, chronic illnesses or conditions that the camper is receiving care from a healthcare provider/physician for on a regular basis.
  1. Has the camper been diagnosed with a seizure disorder or ever suffered from a seizure? If yes, please provide details including: last seizure, type of seizure, medications, known triggers, number of ER visits and hospitalizations. Please attach a copy of your child’s seizure action plan.

Physical Clearance Form P. 2 Camper’s Name ______

  1. Does your child routinely require an aide?
  1. Please list any and all medications, herbs, and supplements that the camper takes, including dosages:
  1. Is the camper allergic to any medication or bee stings? Please list allergies and describe known reactions.
  1. Does the camper have food allergies, intolerances, or is on a special diet? Does the camper’s allergy require them to carry an (EPI) nephrine pen with him/her?
  1. Is the camper current on all their immunizations? If no, please explain:
  1. Has the camper ever had any prior limitations from sports participation?
  1. Has the camper ever passed out during exercise or stopped exercise because of dizziness or chest pain? Has your child ever been diagnosed with a heart murmur, a heart condition, palpitations, or history of rheumatic fever?

Physical Clearance Form P. 3 Camper’s Name ______

  1. Does the camper cough, wheeze, become short of breath or have trouble breathing

during or after an activity?

  1. Has the camper ever had a head injury, concussion, hit or blow to the head that caused confusion, memory problems or prolonged headache?
  1. Has the camper ever suffered a heat related illness such as heat stroke, has heat intolerance, or been told to limit full sun exposure due to their illness?
  1. Is there a history of young people in the camper’s family who have a congenital or other heart disease (i.e. cardiomyopathy, abnormal heart rhythms, long QT or Marafan’s syndrome)? If yes, please describe. Note: You may write I don’t understand these terms/health conditions and initial this item, if appropriate.
  1. Does the camper use alternate forms of communication, such as sign language, pointing to a card, etc.? Please include any helpful hints to better communicate with your child:
  1. Please describe briefly how the camper interacts with others:

Physical Clearance Form P. 4 Camper’s Name ______

  1. Please list any physical needs that the camper may have, including toileting:
  1. Does the camper use a walker, require the use of a wheelchair, or any other adaptive devices? Are there any physical limitations we should know of?
  1. Does the camper have any triggers that cause him/her to become upset? If yes, what are they and how do you help your child regain composure?
  1. Is there anything that you would like to share about the camper that will help staff ensure a safe and enjoyable time for him/her?

The safety of each Bustin Barriers’ participant is a priority. Bustin Barriers reserves the right to request a parent-sponsored aide for a child and/or to evaluate a participant’s appropriateness for services based upon Bustin Barriers’ capacity to meet the needs of the participant.

Parent/Guardian Signature: ______Date: ______